Patient bathrooms and locked doors

Identify states that have implemented actions to ­prevent patient safety risks due to locked doors in patient rooms

Describe types of door locks and how they can be made accessible on both sides in an emergency

Every so often, an incident occurs that brings the topic of locks on patient bathroom doors back to the forefront of our minds. It truly is one of a clinician's nightmares-to know a patient needs help while he or she is in an inaccessible location.

Take, for example, a recent case in which a teenage patient had unexpected respiratory problems while in her hospital bathroom. The facility scrambled to get the door open as the patient struggled to breathe, and in the end, help arrived too late. The hospital now faces a lawsuit.

But regardless of whether your own facility has had a recent incident, now is a good time to look at your policies. Do you and your nursing medical staff, as well as other staff members, know how to get to a patient who falls or passes out behind a locked bathroom door? Are the bathroom doors at your facility even capable of being locked from the inside?

There are several existing laws and regulations that are worth looking at as guidance when creating our own policies.

Seth's Law

Let's first look at the state of Illinois, which has an act known as Seth's Law that addresses this issue.

Section 5 of the Hospital Licensing Act was amended to include the following (under Section 11.6, for those who might wish to track down the original source):

Policy and procedure for patient bathroom door locks. Hospitals shall have policies and procedures for readily gaining access to a locked bathroom in a ­patient's room.

This act was signed into law in 2010 by the governor of Illinois and became a statewide requirement as of January 1, 2011. It became known as "Seth's Law" in honor of Seth ­Sanders, a 22-year-old Iraq War veteran hospitalized in Nevada for a cardiac procedure. ­In September 2009, Sanders died in the hospital after experiencing a medical emergency while hospital staff attempted to gain access to his locked ­bathroom-it took them 10 minutes to reach him.

The law actually toned down initial requirements, which would have either prohibited or very tightly controlled the types of locks allowable on patient bathroom doors. As a result, the requirements set forth by Seth's Law are actually quite reasonable for hospitals to follow.

It is important to note that the law only applies to bathrooms located in patient rooms. No specifics are included in the law's wording, allowing hospitals to craft site-specific policies and procedures that meet the needs of their facility and address the physical layout of their patient rooms.

The Illinois Hospital Association makes the following suggestions for hospitals that are looking to address Seth's Law:

Consider the physical layout of the hospital unit

Consider whether a key is needed to open a locked bathroom door

Look at and develop alternate means of opening a locked door

Think about where the key or other tool to open a locked bathroom door is located

Develop a periodic review process to ensure the staff's knowledge about policies and procedures for expediting entry into a patient's locked bathroom

This last suggestion includes testing the ­knowledge of temporary staff to make sure they know their way around the policies, procedures, and methods for ­opening a locked door in an emergency.

Implementable changes

Where can we turn for more specific processes to put in place that can make the patient room-and specifically the patient bathroom-safer? Let's take a look at one source, NYU's Langone Medical Center, which has created a set of guidelines under its safety policy manual for avoiding in-hospital patient injuries. (Visit http://­webdoc.nyumc.org/nyumc/files/redaf/attachments/205-patsf-11.pdf to read it.)

The policy contains general guidelines for ­patient safety, with the intent of listing environmental conditions that present possible risks to patients, employees, and visitors and explaining how to minimize those risks.

Patient bathing and toilet areas must be equipped with grab bars and nurse call systems

Bathroom doors that are locked from the inside must be equipped with an external lock release mechanism

Water supply temperatures should be automatically regulated so as not to exceed 120 degrees ­Fahrenheit at the shower, bathing, and hand washing units

Obviously, for the purposes of our discussion, the second item is most relevant, but a patient bathroom can be fraught with opportunities for patients to injure ­themselves, and we must be on alert for all of these potential hazards.

The policy addresses the entire patient room by ­including requirements that floors be kept dry and free of slippery material; additionally, when cleaning materials or other hazards are in use, warnings must be in place to alert patients, guests, and staff. Pathways must be kept clear of obstruction as well.

Examples of door precautions

In its Mandatory Training Manual for 2012, the University of California Davis Center for Professional Practice of Nursing has some excellent examples of safety precautions for locks on patient bathrooms. You can view them by visiting www.ucdmc.ucdavis.edu/cppn/documents/mat/WhatsNew2012.pdf.

Staff may open locked patient bathrooms in an ­emergency, the manual states, and it goes on to describe various types of safety precautions:

Type 1: This is a handle with a slot that may be ­oblong or square. An oblong or square blank key can be inserted into the slot and used to open the door in an emergency. According to the manual, almost any key will fit in the oblong slot and work.

Type 2: This is a simple handle with a turnable knob. A care provider should be able to turn the knob ­using his or her fingers to unlock the door from the outside.

Type 3: This lock has a square slot hidden behind a metal cap. The cap is removable by hand, and a square blank key, provided by the plant operation and maintenance, can be used to turn the lock.

Organizations should review their policies and procedures and update accordingly. Consider adding this topic to the new hire orientation and the annual organizational update on patient safety. When ­making rounds, include questions about patient safety and how to open locked bathroom doors. Include inpatient and outpatient areas as well as agency and temporary workers.